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Tonsils and adenoids
- 1. Tonsils and Adenoids Dr.Krishna Koirala 2020-01-27
- 2. • Definition – Palatinetonsils are dense compact bodies of lymphoid tissue located in the lateral wall of the oropharynx, bounded by the palatoglossus muscle anteriorly and the palatopharyngeus and superior constrictor muscles posteriorly and laterally
- 3. Arterial supply oftonsils • Lingual artery: Dorsal linguae branch • Facial artery – Tonsillar branch – Ascending palatine • Ascending Pharyngeal artery • Descending palatine artery
- 4. • Venous drainage –Para tonsillar vein common facial vein and pharyngeal venous plexus internal jugular vein • Lymphatic drainage – Jugulo- digastric lymph node of Woods • Nerve supply – Glossopharyngeal nerve and lesser palatine nerve
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- 6. Relations of tonsillarbed (Inside out) 1. Tonsillar capsule 2. Peritonsillar space with paratonsillar vein 3. Pharyngobasilar fascia , Superior constrictor muscle, Bucco-pharyngeal fascia 4. Styloid process, muscles, glossopharyngeal nerve 5. Internal carotid artery, tonsillar artery 6. Medial pterygoid, submandibular salivary gland 7. Mandible
- 7. Differences between tonsilsand lymph node Tonsils Lymph Nodes Subepithelial Connective Tissue Partly encapsulated Fully encapsulated Efferent only Afferent + Efferent Crypts present Absent No cortex or medulla Present Growth curve present Absent
- 8. Differences between adenoidsand Tonsils Adenoids Tonsils Ciliated columnar epithelium Non-keratinizing squamous epithelium No capsule Partly encapsulated Has furrows Has crypts Peak growth : 6 yrs 8 yrs Growth stops at 12 yrs 15 yrs Disappears at 20 yrs Partial regression at 18 yrs
- 9. Acute tonsillitis • Superficial/ catarrhal: as a part of generalized pharyngitis • Follicular: Crypts filled with pus, visible as yellow- white dots • Membranous: Multiple follicles join to form a yellow-white membrane • Parenchymatous: Infection of lymphoid parenchyma
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- 14. Types of chronictonsillitis • Follicular: crypts filled with pus, visible as yellow- white dots • Parenchymatous: infection of lymphoid parenchyma tonsil enlargement • Fibrotic: small tonsil with hidden pus inside, expressed by pressure on anterior tonsillar pillar (tonsillar squeeze)
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- 16. Signs of tonsillitis •Congested tonsil and tonsillar pillars • Enlarged tonsil (except chronic fibrotic type) • Tonsil squeezed by tongue depressor pressing on anterior tonsillar pillar pus comes out in chronic fibrotic tonsillitis (Irwin Moore sign) • Jugulo-digastric lymph node enlarged ( tender in acute tonsillitis)
- 18. Grades of tonsillarenlargement
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- 23. Complications of acutetonsillitis • Local / locoregional – Recurrent tonsillitis – Intra-tonsillar abscess – Peritonsillar abscess (Quinsy) – Parapharyngeal abscess – Retropharyngeal abscess – Otitis media – Suppurative cervical lymphadenitis • Systemic – Rheumatic fever – Subacute bacterial endocarditis (SABE) – Glomerulonephritis – Septicemia
- 24. Differential diagnosis ofwhite patch on the tonsil • Membranous tonsillitis • Faucial diphtheria • Infectious mononucleosis (Mono spot test) • Candidiasis (throat swab Candida albicans) • Vincent's angina (fusiform bacilli, spirochete) • Tonsillar neoplasm / leukemia (excision biopsy) • Agranulocytosis (Peripheral smear) • Traumatic ulcer (history of trauma) • Keratosis Pharyngis
- 25. Treatment of tonsillitis •Bed rest • Adequate hydration • Systemic antibiotics: ampicillin, erythromycin , ceftriaxone, cefuroxime, amoxyclav • Antihistamines and decongestants • Analgesics • Antiseptic gargle • Treatment of focus of infection
- 26. Differences between Membranous Tonsillitis Diphtheria Age > 5yr 2- 5 yr Onset Acute Insidious General Symptoms More Less Odynophagia More Less Temperature High Low Tachycardia Proportionate Disproportionate Tonsils Enlarged, congested Normal
- 27. Membranous tonsillitis Diphtheria Membrane Bilateral Whitish yellow Thin Limitedto tonsil Easily removed May be unilateral Gray Thick May go beyond Bleeds on removal Culture Hemolytic streptococci Corynebacterium diphtheriae Lymph node Jugulo-digastric Generalized (Bull neck)
- 28. Treatment of faucialdiphtheria • Isolation and bed rest • I.V. benzyl penicillin 600 mg q6h • Diphtheritic anti - toxin infusion in saline – 20,000 – 40,000 U : 48 hrs duration, tonsillar – 40,000 – 80,000 U : nasopharynx / larynx – 80,000 – 120,000 U : 48 hrs, neck edema • Emergency tracheostomy required for stridor
- 29. Tonsillolith and Tonsillarcyst Recurrent tonsillitis / retention of debris Blockage of tonsillar crypts pus and debris calcify yellow colored inclusion cyst Tonsillolith tonsillar cyst
- 30. Tonsillolith and Tonsillarcyst contd…... • Clinical features – Halitosis, bitter taste in mouth – White outgrowths from tonsillar crypts or yellow cyst in supra-tonsillar cleft • Treatment – Asymptomatic drainage of cyst or manual expression of tonsillolith – Severe symptoms tonsillectomy
- 31. Keratosis pharyngis • Benign, self limiting condition • Etiology : Smoking, alcohol, vitamin A deficiency • O/E: – Yellowish, horn-like outgrowths from mucosa of tonsil that cannot be wiped off • Histopathology : – Hypertrophy and hyperkeratinization of epithelium – Absence of inflammation • Treatment: – Reassurance – Tonsillectomy in severe cases
- 32. D/D of Unilateraltonsillar enlargement • Tonsillar causes – Tonsillar malignancy – Peritonsillar abscess – Intra-tonsillar abscess – Tonsillolith – Tonsillar cyst – Tonsillar artery aneurysm – Vincent's angina • Extra-tonsillar causes – Parapharyngeal abscess – Parapharyngeal tumors – Tumors of deep parotid lobe – Internal carotid art. aneurysm – Cervical lymphadenopathy
- 33. Adenoids • Symptomatic, hypertrophicnasopharyngeal (Luschka's) tonsils • Adenoids lead to – Nasal obstruction Mouth breathing – Eustachian tube block OME • Features like adenoids are also seen in – Dental mal-occlusion – B/L nasal block ( Nasal polyps, choanal atresia)
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- 35. • Features ofnasal obstruction – B/L nose block & nasal discharge – Rhinolalia clausa (flat toneless voice) – Difficulty in feeding – Snoring – Pulmonary hypertension – Pinched nostrils (due to disuse atrophy)
- 36. • Features ofmouth breathing – Open mouth, dribbling of saliva – High-arched palate (d/t moulding action of tongue) – Crowding of teeth, protruding central incisor – Hitched upper lip (hare lip) – Under shot mandible – Chronic pharyngitis (by breathing impure air)
- 37. • Features ofEustachian tube block – Earache – Conductive deafness (due to O.M.E.) – Dull, expressionless look – Inattentive child • Other Features – Pectus excavatum – Nocturnal enuresis
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- 39. Plain X-ray softtissue nasopharynx lateral view
- 40. Management • Diagnosis – Nasopharyngoscopy rigid / flexible – Plain X–ray soft tissue nasopharynx lateral view with head extended adenoid mass • Treatment – Mild symptoms antihistamine + decongestant – Severe symptoms adenoidectomy